Provider Demographics
NPI:1669965745
Name:WEBER, JOHN MARK (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:WEBER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 REGAL DR
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-5204
Mailing Address - Country:US
Mailing Address - Phone:605-924-0865
Mailing Address - Fax:
Practice Address - Street 1:412 W SD HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9369
Practice Address - Country:US
Practice Address - Phone:605-924-0865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD11861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice